Take a Minute to Get and Give a Nutrition Message

Nutrition therapy has been recognized as a primary treatment strategy for diabetes since the condition was identified centuries ago. The recently published American Diabetes Association (ADA) Nutrition Recommendations and Interventions for Diabetes—2006 is sure to help guide you and your patients in the new millennium.¹ As a clinician, you are in a great position to use these recommendations during routine contact with patients to address the challenges of leading a healthy life-style to prevent or manage diabetes.

“WE MUST BELIEVE [PATIENTS] CAN ACHIEVE HEALTH BEHAVIOR CHANGE.”

CHANGE US, THEM, OR BOTH?

To help our patients apply nutrition recommendations, we must believe they can achieve health behavior change. And yet, as cultural anthropologist Margaret Mead said, “It is easier to change a man's religion than to change his diet.”

In a survey of >2,000 adults with diabetes, the most frequently cited barrier to achieving self-management goals was adherence to diet and exercise.² Although data from the Third National Health and Nutrition Examination Survey (NHANES III) confirm that individuals with diabetes are eating too much fat, not taking in enough fruits and vegetables, and leading inactive lifestyles,³ getting patients to take a pill or injection can be easier than convincing them to lose a few pounds, count carbohydrates, or start a physical activity program.

However, medical nutrition therapy (MNT) does make a difference.⁴ In the Diabetes Prevention Program, the incidence of diabetes was reduced 58% in the lifestyle group compared with 31% in the metformin group.⁵ Diabetes MNT trials and outcome studies have demonstrated reductions in glycated hemoglobin (A1C) of ∼1% in type 1 diabetes and 1–2% in type 2 diabetes, depending on the duration of the diabetes. These results are similar to A1C reductions achieved with drug treatment.¹ MNT also plays a role in lowering blood pressure and lipids.¹

As clinicians, we have the perfect opportunity to be the change agent that helps patients lead healthier lives. When a physician provides advice regarding weight loss, for example, patients are nearly three times as likely to act on that recommendation as patients who do not receive the advice.⁶ And patients are more satisfied with their interactions with us when they receive information, support, and resources, especially when our messages are positive, nonjudgmental, and understanding of the difficulties of changing health behavior.⁷

1-MINUTE LIFESTYLE MESSAGES

Research suggests that physicians spend <0.7 minutes on health promotion when averaged across all visits, and <1.35 minutes during the visits in which they give health promotion advice.⁸ Often, more time is spent on health education related to illness care (i.e., up to 1.98 minutes). Because clinicians are busy, the concept of 1-minute messages was developed.⁹ Using that approach, we have created some brief nutrition messages based on the three levels of diabetes-related prevention categories outlined in ADA's 2006 recommendations:

Primary Prevention

Insulin resistance (weight loss and/or regular physical activity)

Based on your fasting blood glucose level and your weight, you have insulin resistance. You are at risk of developing type 2 diabetes.

1. Modest weight loss has been shown to improve insulin resistance, and this can help keep your blood glucose at healthy levels.

2. If you lose 5–10% of your body weight (about 4.5–6.8 kg or 10–15 lb), you can improve insulin resistance. Moderate weight loss not only improves your blood glucose level but also can lower your blood pressure and cholesterol level.

3. Regular physical activity, such as 30 minutes of walking 5 days per week, can improve insulin resistance.

4. Regular physical activity can help you maintain your current weight or help you maintain weight loss.

Secondary Prevention

Meal planning

1. The amount of carbohydrate you eat at a meal determines how much your blood glucose will rise after eating. The recommended peak blood glucose level 1–2 hours after the beginning of the meal should be <180 mg/dl.¹⁰

2. Carbohydrates are an important part of a balanced diet and should not be eliminated from your food plan. When treating your diabetes with medications, we try to match the doses of insulin or the action of your diabetes pills to the carbohydrate content of your meals.

3. To help you achieve healthy blood glucose targets after your meals, I am going to refer you to a registered dietitian who is knowledgeable and skilled in developing an individualized diabetes meal planning approach.

Tertiary Prevention

Cardiovascular disease risk

• To reduce your risk for heart disease, your food plan should include several servings each day of fresh or frozen fruits and vegetables and whole grains. You may include natural peanut butter and nuts in moderation, as they are also healthful foods.

High blood pressure

1. As a person with diabetes and high blood pressure, you may benefit from losing a moderate amount of weight (4.5–6.8 kg or 10–15 lb).

2. You may be able to lower your high blood pressure by eating less sodium. You want to keep it to 2,300 mg/day (or 700–800 mg/meal). Regularly including fruits, vegetables, and low-fat dairy products in your food plan also helps.

Kidney disease

1. Your kidney function test results indicate that your kidney function has declined. To slow the decline, eat smaller portions of protein and manage your blood pressure and blood cholesterol.

2. Based on your current test results, popular high-protein and low-carbohydrate weight-loss diets are not healthy for your kidneys.

INCLUDE MNT PAYMENT RESOURCES

Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes as well as a registered dietitian.¹ Unfortunately, only 35% of people with diabetes are estimated to be receiving formal diabetes self-management education.¹¹ Yet many health management organizations and private payers now include an MNT benefit, and most of the 50 states have mandates for coverage of diabetes self-management training and MNT. Flexible spending accounts also can be used to cover the cost of nutrition and/or diabetes education.

So if your diabetes patients are struggling to achieve the ADA recommendations, refer them to a registered dietitian or certified diabetes educator at your local hospital outpatient diabetes education program, a freestanding diabetes education center, or a professional in private practice. MNT is an effective treatment strategy for preventing and managing diabetes if you make the referral.

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